Society for Maternal‐Fetal Medicine Special Statement: Incorporating quality improvement roles into your maternal‐fetal medicine career

Abstract

In July 2023, the Society for Maternal‐Fetal Medicine (SMFM) Patient Safety and Quality Committee (PSQC) hosted a facilitated panel discussion focused on how to incorporate quality improvement (QI) and patient safety roles into a maternal‐fetal medicine (MFM) career. In addition, the SMFM PSQC conducted an online survey of SMFM members via the SMFM May 2024 member newsletter to gain further insight into the roles, responsibilities, and allotted time for MFM subspecialists involved with QI efforts. This document reports on key themes and practical strategies that emerged from both the SMFM PSQC panel session and SMFM survey responses to begin and sustain QI‐focused MFM careers.

1. INTRODUCTION

The mission of the Society for Maternal‐Fetal Medicine (SMFM) Patient Safety and Quality Committee (PSQC) is to evaluate, promote, and advance quality, patient safety, and health equity within the field of high‐risk obstetrics. The committee is charged with establishing metrics to evaluate quality and safety in maternal‐fetal medicine (MFM) practice. It also develops materials to assist MFM subspecialists in providing leadership in quality, patient safety, and health equity at hospital and organizational levels. To that end, in July 2023, the SMFM PSQC hosted a facilitated panel discussion focused on how to incorporate quality improvement (QI) and patient safety roles into an MFM career. Panelists included current and past PSQC members with breadth and depth of QI careers across a spectrum of practice models, geographies, and career stages. Table 1 describes the panelists and their professional backgrounds.

TABLE 1.

Panelist information and professional background.

Name	Role	Institution	Years post‐fellowship
Christina Davidson, MD	Chief Health Equity Officer	Baylor College of Medicine/Texas Children's Hospital	17 years
Sindhu Srinivas, MD, MSCE	Associate Chief Medical Officer—Quality and Safety	University of Pennsylvania	16 years
Fouad Atallah, MD	Hospital Vice Chief of Obstetrics	Weill Cornell Medicine	3 years
Dena Goffman, MD	Vice Chair for Quality and Patient Safety, System Associate Chief Quality Officer for Obstetrics (concurrent)	NewYork‐Presbyterian/Columbia University Irving Medical Center	16 years
C. Andrew Combs, MD, PhD	Senior Advisor for Maternal‐Fetal Medicine Clinical Quality	Pediatrix and Obstetrix	34 years
Rebecca Hamm, MD, MSCE (panel facilitator)	Chair, Patient Safety and Quality Committee, Society for Maternal‐Fetal Medicine	University of Pennsylvania	4 years

To gain further insight into the roles, responsibilities, and allotted time for MFM subspecialists involved with QI efforts, the SMFM PSQC conducted an online survey of SMFM members via the SMFM May 2024 member newsletter (Special Delivery). Of the 36 responses received, 26 respondents indicated they hold a QI‐related role within or outside their organization. Of those, 15 were at the division or department level, and 10 were at the institution level. Further, 15 respondents shared information about the amount of protected time they received for their quality roles, representing a wide range. Of those, seven received no protected time, while two had more than 50% of their time dedicated to QI work. Of those who shared information on protected time, two thirds of the respondents did not feel that they received sufficient protected time for their QI role. While only a small percentage of the SMFM membership responded, these results highlight a dedication to QI within the field of MFM, as well as the need for further resources to support QI leadership.

In 2023, the SMFM PSQC published a curriculum for patient safety and quality for MFM fellow physicians, which aims to educate trainees on the knowledge and skills needed to perform QI projects in their institutions or health systems [1]. This Special Statement, on the other hand, seeks to empower MFM subspecialists across experience levels and practice types to incorporate QI leadership into their careers by highlighting key themes and practical strategies that emerged from both the SMFM PSQC panel session and SMFM survey responses.

2. INSPIRATIONS FOR MFM SUBSPECIALISTS TO PARTICIPATE IN QI

As expressed by participants during the panel session, MFM clinicians may choose to incorporate QI roles into their careers for a variety of reasons. Physicians may have experienced clinical error firsthand, thereby recognizing their own fallibility without safety checks. Participation in QI may be driven by a desire to reduce inequities in obstetrical outcomes or by experiences that suggest reshaping systems and sustaining better outcomes is possible. They may have embarked on a formal research project but found themselves frustrated by the lengthy timeline from traditional research to practice change. MFM subspecialists may have participated in quality initiatives at their clinic or institution that had substantial effects on patient care, inspiring them to enact such changes elsewhere as they move positions.

While many members of the patient care team, including general obstetrician/gynecologists, nursing leaders, and family medicine clinicians, have the expertise and determination to advance quality and safety, panelists expressed how MFM subspecialists may have a unique vantage point to take on QI leadership roles in obstetrics. Specifically, MFM subspecialists provide patient care across the outpatient and inpatient settings, throughout prenatal care and perinatal diagnosis and imaging, and among low‐ and high‐risk populations. Education in patient safety and quality is also now considered an essential component of MFM fellowship training [1]. With these perspectives and skillsets, panelists expressed the opinion that it is imperative for MFM subspecialists to serve as QI leaders at their institutions and within their health systems and to be involved with regional or federal initiatives. Ultimately, the goal is to place QI leadership in the hands of those who are not only passionate but also specifically trained, experienced, and deeply embedded in the clinical realities of obstetrical care. MFM subspecialists—with their comprehensive understanding of complex pregnancy, ability to navigate across care settings, and growing expertise in quality methodologies—are well‐positioned to drive meaningful improvements. At the heart of these efforts is a shared commitment to deliver safer, more equitable, and higher‐quality care for pregnant patients.

3. WHAT CAN QI ROLES LOOK LIKE?

Panelists discussed how the path to assuming a QI role will vary depending on a physician's practice setting, distribution of responsibility, and goal(s). Nearly all panelists expressed that their journey to QI leadership roles did not follow a pre‐specified trajectory. Several began their QI careers in more general leadership roles, such as hospital chief or director of obstetrics, merging QI with their other interests, such as research or simulation. Other panelists described initial roles focused on QI, including outpatient clinic or ultrasound unit directors, or leading a specific QI initiative–based workgroup. A common career trajectory was advancement from these more localized or obstetrical‐focused roles into system‐wide or even statewide leadership roles that may also include overseeing QI efforts beyond obstetrics. While some paths overlapped, Figure 1 depicts the diversity of panelists’ career paths, QI training, and roles and responsibilities.

FIGURE 1.

Career trajectories of PSQC leaders in quality improvement and patient safety. The figure illustrates several maternal‐fetal medicine career trajectories and their quality improvement roles across regional, hospital, departmental, and training levels. CMO, chief medical officer; LoMC, levels of maternal care; MFM, maternal‐fetal medicine; OB/GYN, obstetrics and gynecology; PQC, perinatal quality collaborative; PSQC, Patient Safety and Quality Committee; SMFM, Society for Maternal‐Fetal Medicine.

4. WHAT IS NEEDED TO BEGIN A CAREER IN QI

Panelists identified several critical components for the MFM subspecialist to begin a QI career.

4.1. Mentorship and sponsorship

First, participants discussed the value of internal mentorship and sponsorship, often provided by a division director or department chair. One of the biggest advantages of internal mentorship is the mentor's understanding of an institution's unique culture and systems. It allows the mentor to guide the mentee on obtaining approval for QI initiatives, working with hospital administration, and aligning QI goals with the organization's strategic priorities. Internal mentors can also recommend specific resources available within the institution. Effective mentors actively engage mentees directly in the department's ongoing QI projects, allowing them to experience the challenges and successes of improving care delivery within their specific context, which can then be applied to future efforts. Internal mentors also help mentees build relationships with key stakeholders across the institution, including clinical staff, administrators, and other departments. Participants also discussed some challenges with internal mentorship, including mentors’ limited exposure to practices and ideas outside the institution, potentially limiting the mentee's ability to pursue more radical QI improvements.

Panelists discussed that having an external mentor can provide a broader perspective on the challenges and opportunities within MFM and QI, offering guidance that goes beyond the confines of a single healthcare system. These mentors might be experienced MFM subspecialists or non‐MFM QI experts from other institutions, state quality collaboratives, or national professional organizations.

In addition to mentorship, participants also spoke about the value of sponsorship in QI career development. A sponsor is typically a senior leader who helps create opportunities and visibility that may not have been accessible otherwise—such as securing committee appointments, recommendations for leadership roles, or nominations for speaking engagements. In MFM, effective sponsors can help elevate early‐career physicians into institutional or regional QI leadership, facilitating career progression and system‐level impact.

4.2. Formal training: Acquiring the tools of improvement science

To successfully lead in QI, panelists discussed how MFM physicians should acquire shared language and foundational skills. To do so, some MFM subspecialists pursue formal degrees (e.g., a master's degree in public health or health quality and safety) or graduate certificates in healthcare quality, patient safety, or implementation science, often facilitated through part‐time or executive programs. Some centers have begun offering obstetrics and gynecology‐ or MFM‐specific quality and safety training, such as one‐year focused fellowships. Numerous certifications offer structured, competency‐based validation of QI proficiency; some examples discussed by participants are shown in Table 2, but this list is in no way exhaustive.

TABLE 2.

Examples of quality and patient safety training and certification opportunities [2, 3, 4, 5, 6].

Program/certification	Description	Focus areas	Audience/use
Institute for Healthcare Improvement Open School	Free online modules introducing key concepts in quality improvement, patient safety, and leadership.	QI, patient safety, leadership, health systems science	Ideal for early exposure
Certified Professional in Patient Safety	Credential covering core patient safety domains and practices. Recognized across clinical specialties.	Systems thinking, safety culture, risk mitigation, performance measurement	Healthcare professionals seeking patient safety expertise
Certified Professional in Healthcare Quality	Offered by NAHQ, this credential encompasses quality‐related domains for healthcare professionals.	Quality measurement, data management, performance improvement	Broadly applicable across healthcare settings
Obstetric and Neonatal Quality and Safety subspecialty certification	Validates knowledge and skills in applying QI to maternal and neonatal care. Administered by the National Certification Corporation.	QI in obstetrical and neonatal care	OB/GYNs, MFMs, nurses, and other perinatal care professionals
Lean Six Sigma	Methodology aimed at improving efficiency and reducing waste in processes. Adaptable to healthcare settings.	Process efficiency, waste reduction, clinical workflow optimization	Particularly useful in high‐volume settings, e.g., L&D or clinics

Abbreviations: L&D, labor and delivery unit; MFMs, maternal‐fetal medicine subspecialists; NAHQ, National Association for Healthcare Quality; OB/GYNs, obstetrician/gynecologists; QI, quality improvement.

4.3. Leadership skills

Panelists expressed that understanding the fundamentals of QI methodologies was insufficient without the necessary leadership skills to garner cooperation. One panelist stated:

Most of your QI efforts are going to be large, multidisciplinary projects that you need to implement with people across the hospital and not just the physicians, not even just the physicians and nurses, but you may be partnering with pharmacy and just a lot of different areas.

While leadership skills can be obtained through practical learning, SMFM and other organizations offer structured leadership curricula, such as the SMFM Leadership Academy, which may be specifically useful in honing skills to obtain buy‐in for change and developing an understanding of change management strategies [7]. The Institute for Healthcare Improvement (IHI) also offers advanced training for leadership in both QI and health equity:

• IHI Leading Quality Improvement: Essentials for Managers: This course is designed to enhance engagement and deepen understanding of QI to improve organizational efficiency [8].

• IHI Leadership for Health Equity Professional Development Program: This program equips participants with tools to strengthen their organization's approach to health equity by applying practical tools, relational strategies, and effective language to build momentum and foster team‐based action [9].

4.4. Starting local

One of the most accessible entry points into QI work is participation in local quality committees, maternal morbidity and mortality reviews, or perinatal case review conferences. These opportunities, which may be more focused on quality assurance than improvement work, help with understanding quality challenges and identifying actionable gaps in care.

4.5. Interdisciplinary collaborations

Panelists discussed how effective QI is inherently collaborative. No single clinician can improve systems in isolation; success requires the involvement of multidisciplinary teams with diverse expertise including but not limited to obstetricians, neonatologists, anesthesiologists, nurses, sonographers, genetic counselors, laboratory technicians, patients, communities, and administrative staff. Another important theme that emerged through the discussions was the importance of data. Participants highlighted the crucial step of developing data streams through analytics support, understanding that “good data” (i.e., robust data platforms that can extract patient characteristics and outcome variables from the electronic health record) are critical to QI success and that individual chart review will never be a sustainable means of supporting QI work at scale.

4.6. “No quality without equity”

Panelists discussed that MFM physicians participating in and leading QI work must consider equity in both design and outcome. This principle includes analyzing disparities in outcomes by race, ethnicity, insurance status, language, and other social drivers of health. Panelists discussed that just as QI requires specific tools, so does equity‐focused work. Training in health equity, structural racism, and social drivers of health is essential for ensuring that improvement efforts do not unintentionally reinforce, worsen, or create disparities.

4.7. Tenacity and resilience

Panelists emphasized the importance of passion, persistence, and tenacity for QI leaders. They noted that going into QI with the “right attitude” is of utmost importance: burnout is a real threat. QI leaders should believe that clinical care can always improve, but also recognize that not everything can be fixed quickly. Meaningful changes and improvements come with time.

4.8. Preparing for leadership

Panelists discussed the value of starting small and demonstrating effectiveness by tackling “low‐hanging fruit” early in the QI career trajectory and publishing both positive and negative studies to demonstrate productivity. Many also discussed making an interest in QI clear in any job search, proving local QI productivity, and, if possible, advocating for protected time in which to do QI work. Allocation of time to focus solely on QI allows the following three important aspects of work to be conducted:

• Time for conception, consultation, and “deep work.” It is important to allow leaders in patient safety and QI to dedicate time to learning, thinking, and designing QI projects.

• Time for dissemination and implementation.

• Time for audit and feedback. An assessment or measurement of the variables related to the project is necessary to evaluate the success of any QI project. Providing feedback requires a thoughtful and candid approach, especially when it is a project regarding individual performance.

5. CHALLENGES TO AND STRATEGIES FOR A SUCCESSFUL MFM CAREER IN QI

The pursuit of QI as a major career focus is not without challenges. This section focuses on challenges identified in the SMFM panel session and survey results, while providing suggested strategies to address these effectively.

5.1. Imposter syndrome

Panelists spoke about the experience of imposter syndrome (defined as the persistent inability to believe that one's success is deserved or has been legitimately obtained) as QI leaders, especially when they may have begun QI‐focused work mid‐career [10, 11, 12]. Mid‐career MFM subspecialists pointed out that, although QI education is a standard part of MFM training now, it was not during the time of their clinical training. In response, panelists underscored the value of experiential learning while undertaking QI projects throughout an MFM career.

5.2. Pressure to perform more “traditional” research

Traditionally, research in perinatology has focused on methodologies rooted in clinical and translational science, basic science, health outcomes research, and quantitative/health services research. Pressure for research productivity may come from the required MFM thesis, from mentors, or from within. Over the past decade, there has been an evolving focus on implementation and improvement science as legitimate avenues for research endeavors [13, 14]. Yet, challenges remain. For instance, the lack of funding opportunities for scholarly improvement science can be an impediment to furthering academic productivity in this field. When an individual's goals include both QI and research, panelists discussed the value of weaving QI‐related specific aims into larger research projects that fall under the realm of clinical or implementation science research to advance the scholarship of QI.

5.3. Cultivation of relationships

While the conversation around beginning a QI career focused on obtaining mentorship and understanding the interdisciplinary collaboration required for QI, panelists expressed that relationship‐building for QI requires time. Panelists suggested that, especially when taking on new roles and even at later career stages, MFM physicians take the time to understand the workflows of relevant project stakeholders (e.g., other physicians, including trainees; nurses; and medical assistants, among others) and garner support of frontline clinicians to make QI initiatives successful.

5.4. Lack of leadership support for QI

An essential element for individuals aiming to pursue a career in QI is support from departmental and institutional leadership. Panelists discussed several specific challenges:

• Lack of recognition around academic productivity through QI

• Lack of awareness about QI as a niche in administrative leadership

• Lack of a structured mechanism for promotion in academic institutions for individuals with predominantly QI‐focused work

• Lack of departmental and institutional support in terms of dedicated percentage effort coverage

• Lack of effort coverage for QI roles outside an MFM subspecialist's primary institution (e.g., local/state perinatal quality collaboratives, maternal mortality review committees, or national professional organizations)

Panelists offered strategies to overcome these barriers. First, panelists suggested developing a systematic plan to demonstrate the return on investment that QI activities can have, through clinical metrics or patient experience measures. Linking return on investment to external reporting requirements—such as those from The Joint Commission or the Centers for Medicare & Medicaid Services—can be a useful tactical strategy [15, 16]. Likewise, panelists discussed that it may be helpful to identify projects that align with departmental and institutional goals, at least initially, to show value in this work.

5.5. Site‐specific challenges

Lack of site‐specific resources, such as data analytics and buy‐in from colleagues (e.g., nursing staff, hospital administration), as well as engagement across relevant specialties, such as anesthesiology or pediatrics, can pose a major challenge for local leadership in QI. Effective strategies to address these issues include starting with a targeted project that involves a smaller team or demonstrating success and capitalizing on the resulting impact. Small wins can generate system‐level traction. Lastly, while initiating QI projects can seem like a difficult task, panelists also focused on the challenge of sustaining QI endeavors. Panelists discussed that a career in QI can seem overwhelming if an infrastructure to center re‐implementation—in other words, continuously and actively working to put a practice back into care when use slips—is not built into the local system [17]. In short, it cannot be up to one person to both develop and test new QI initiatives to improve patient care and then sustain each initiative in perpetuity.

5.6. Moving up and away? From local to system leadership

Finally, panelists discussed that success in QI can lead to career advancement, which can reach beyond MFM and even beyond obstetrics and gynecology. Panelists spoke about the rewarding nature of using QI skills for a larger purpose, such as improving quality across medical disciplines, and having reproductive health representation at the hospital and systems levels.

6. CONCLUSION

This Special Statement summarizes key themes from an SMFM expert panel and membership survey regarding QI leadership, including what is needed to begin and challenges and strategies for a long‐term QI career. Panelists and members demonstrated an appreciation for the value of QI in an MFM career, recognizing both that QI endeavors are heavy lifts and that QI remains one of the most impactful levers we have to improve reproductive health. As such, QI skills are now of great value in hiring and mentorship, and we should continue to support MFM subspecialists as they reach towards successful QI leadership, with the overarching goal of improving reproductive health broadly. Table 3 outlines steps individuals, departments, institutions, and professional societies can take to support MFM subspecialists in their QI careers.

TABLE 3.

Recommendations for institutions and practices in supporting MFM subspecialists as QI leaders.

Recommendation	Description
Establish structured mentorship programs.	Develop comprehensive mentorship programs that connect MFM subspecialists interested in QI with experienced mentors, both within and outside the department.
Allocate resources for formal QI training.	Provide dedicated resources, including appropriately suited protected time and financial support, to enable MFM specialists to pursue formal training in QI methodologies and leadership.
Formalize QI leadership positions.	Create clearly defined QI leadership roles within the department or practice.
Grant protected time for QI leaders.	Allocate protected time for designated QI leaders to conceptualize, execute, and disseminate high‐quality QI initiatives.
Develop robust data infrastructure and support.	Implement advanced data systems supported by experienced personnel to empower QI leaders in their work.
Promote interdisciplinary QI leadership.	Encourage MFM subspecialists to assume QI leadership roles that extend beyond obstetrics.

Abbreviations: MFM, maternal‐fetal medicine; QI, quality improvement.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

7.

The use of this information is voluntary, and clinicians should be familiar with and comply with all applicable laws and regulations.

All authors and committee members have filed a disclosure of interests delineating personal, professional, business, or other relevant financial or nonfinancial interests in relation to this publication. Any substantial conflicts of interest have been addressed through a process approved by the Society for Maternal‐Fetal Medicine (SMFM) Board of Directors. SMFM has neither solicited nor accepted any commercial involvement in the specific content development of this publication.

This document has undergone an internal peer review through a multilevel committee process within SMFM. This review involves critique and feedback from the SMFM Patient Safety and Quality Committee and Document Review Committee and final approval by the SMFM Executive Committee. SMFM accepts sole responsibility for the document content. SMFM publications do not undergo editorial and peer review by Pregnancy. The SMFM Patient Safety and Quality Committee reviews publications every 24 to 36 months and issues updates as needed. Further details regarding SMFM publications can be found at www.smfm.org/publications.

SMFM recognizes that obstetrical patients have diverse gender identities and strives to use gender‐inclusive language in publications. SMFM uses terms such as “pregnant person” and “pregnant individual” and the singular pronoun “they.” When describing study populations used in research, SMFM uses the gender terminology reported by the study investigators.

All questions or comments regarding the document should be referred to pubs@smfm.org.

Reprints will not be available.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.